Provider Demographics
NPI:1972583128
Name:TARASEVICH, SANDRA JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:JEAN
Last Name:TARASEVICH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 ROUTE 202
Mailing Address - Street 2:BLDG A, 2ND FLOOR - MAILBOX #7
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-3207
Mailing Address - Country:US
Mailing Address - Phone:914-669-9144
Mailing Address - Fax:914-669-1035
Practice Address - Street 1:340 ROUTE 202
Practice Address - Street 2:BLDG A, 2ND FLOOR - MAILBOX #7
Practice Address - City:SOMERS
Practice Address - State:NY
Practice Address - Zip Code:10589-3207
Practice Address - Country:US
Practice Address - Phone:914-669-9144
Practice Address - Fax:914-669-1035
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-21
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT005613152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP1961894OtherOXFORD ID
NY597225OtherMVP ID
NY6599675OtherGHI ID
NY4C1816OtherHEALTHNET ID
NY007934OtherCONNECTICARE ID
NY7636057OtherAETNA ID
NYC1T481OtherBCBS ID
NY007934OtherCONNECTICARE ID
NYC58601Medicare ID - Type Unspecified